No Love at First Breath? The Utilization of Lung-Protective Ventilation Across Anesthesia Resident Training Levels

Document Type

Conference Proceeding

Publication Date

5-1-2025

Publication Title

Anesth Analg

Keywords

Anesthesiology

Abstract

Introduction: Previous studies suggested that the training level of an anesthesia resident is associated with differences in intraoperative hemodynamic management and differential risks of post-extubation desaturation [1-2]. In patients undergoing general anesthesia for surgery, lung-protective ventilation is an important intraoperative intervention that helps prevent postoperative respiratory complications [3-4]. It is unclear whether the training level of an anesthesia resident is associated with differential utilization of lung-protective ventilation strategies. In this study, we investigated whether the training level of anesthesia residents is associated with differential utilization patterns of lung-protective ventilation.Methods: This retrospective cohort study included 100,771 adult patients who underwent surgery under general anesthesia with endotracheal intubation between 2008 and 2024, where residents provided anesthesia care under attending supervision at a tertiary academic healthcare network in Massachusetts (Figure 1). The primary exposure was the training level of the anesthesia resident (clinical anesthesia year 1 [CA-1] versus CA-2 versus CA-3). The primary outcome was lung-protective ventilation, defined as driving pressure < 15 cmH2: O. In secondary analyses, we assessed the utilization of low tidal volumes (6-8 mL/kg ideal body weight) and lower respiratory rates ( ≤ 12 breaths/minute). Multivariable logistic regression analyses, adjusted for several patient-related and procedural characteristics, were used to investigate the association between resident training level and ventilation patterns. In exploratory analyses, we studied the translation of the primary findings into postoperative respiratory complications, defined as a composite of post-extubation desaturation (SpO2 < 90% within 10 minutes after extubation) and initiation of emergency non-invasive ventilation or invasive mechanical ventilation within 7 days after surgery. Results: A total of 46,992 (46.6%) patients received anesthesia care from CA-1 residents, while 22,299 (22.2%) and 31,480 (31.2%) were treated by CA-2 and CA-3 residents, respectively. Patients who received anesthesia care from CA-3 compared to CA-1 residents had a higher comorbidity burden, while there were only minor differences in the surgical complexity (Table 1). Compared to CA-1 residents, the likelihood of low driving pressure utilization was higher if CA-2 or CA-3 residents provided anesthesia care (CA-2: adjusted odds ratio [ORadj] 1.15; 95% confidence interval [CI] 1.10–1.20; p<0.001 and CA-3: ORadj 1.14; 95%CI 1.10–1.19; p<0.001; Figure 2). Similar associations were seen for the utilization of low tidal volumes (CA-2: ORadj 1.10; 95%CI 1.06–1.15; p<0.001 and CA-3: ORadj 1.12; 95%CI 1.08–1.17; p<0.001; Figure 2), while lower respiratory rates were less frequent in CA-2 and CA-3 residents compared to CA-1 residents (CA-2: ORadj 0.92; 95%CI 0.88–0.96; p<0.001 and CA-3: ORadj 0.81; 95%CI 0.78–0.84; p<0.001; Figure 2). The risk of postoperative respiratory complications was lower if CA-3 compared to CA-1 provided anesthesia care (ORadj 0.91; 95%CI 0.85–0.98; p=0.012), which was primarily driven by a lower risk of post-extubation desaturation (ORadj 0.91; 95%CI 0.84–0.98; p=0.014).Conclusions: Anesthesia residents at higher training levels had a higher likelihood of maintaining lower driving pressures and tidal volumes than early-career residents, while the utilization of low respiratory rates was highest among CA-1 residents. These findings translate into lower risks of post-extubation desaturation among more experienced residents. Our results help inform the development of teaching curricula for anesthesia residency programs across the United States.

Volume

140

Issue

5

First Page

1135

Last Page

1137

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